Compliance with Recommendations for Prevention and Detection of Controlled-substance Diversion in Hospitals

Steven R. McClure; Brian C. O'Neal; Dennis Grauer; Rick J. Couldry; Allison R. King

Am J Health Syst Pharm. 2011;68(8):689-694.

Conclusion

The results of a survey of directors of pharmacy at a sample of U.S. institutions (hospitals that had pharmacy residency programs or were UHC members) suggest wide variation in facilities' use of recommended practices for the prevention and detection of controlled-substance diversion.

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The authors have declared no potential conflicts of interest.

Table 1. Demographic Characteristics of Survey Respondents (n = 135)
Characteristic	No. (%) Respondents
Characteristic	Hospitals With 1–399 Beds (n = 59)	Hospitals With ≥400 Beds (n = 76)
Hospital setting^a
Rural (population ≤50,000)	16 (27)	2 (3)
Urban (population >50,000)	43 (73)	74 (97)
Type of institution^a
Private, for-profit	1 (2)	5 (7)
Private, not-for-profit	34 (58)	61 (80)
State or government	24 (41)	10 (13)

^aSignificant difference between small and large hospitals (p < 0.05).

Table 2. Compliance With Selected Recommended Practices for Diversion Detection and Prevention^a
Practice	No. (%) Respondents Following Recommendation		p
Practice	Hospitals With 1–399 Beds (n = 59)	Hospitals With ≥400 Beds (n = 76)	p
Pharmacy
Witness and documentation required for wasting of controlled substances	57/59 (97)	72/76 (95)	>0.05
If an expired-returns company is used, DEA form 222 provided by company is reconciled against central pharmacy vault inventory	48/54 (89)	62/71 (87)	>0.05
Audit of controlled substance purchases against products added to pharmacy inventory performed at least quarterly	50/58 (86)	64/76 (84)	>0.05
Automated vault for storage of controlled substances used	44/59 (75)	73/75 (97)	0.001
If CSOS not used, log of DEA form 222 kept to ensure all are accounted for^b	34/43 (79)	52/58 (90)	>0.05
Individual who submits a controlled-substance purchase order not responsible for receiving the order	43/59 (73)	66/76 (87)	0.049
Use and waste of multidose vials of controlled substances audited	39/57 (68)	58/74 (78)	>0.05
Discrepancies reviewed by individual not routinely involved in controlled-substance handling	40/59 (68)	55/75 (73)	>0.05
Person-to-person transfers of controlled substances audited, including transfers to nonautomated storage areas	48/59 (81)	46/75 (61)	0.014
Cameras directed at controlled-substance storage areas	32/58 (55)	54/74 (73)	0.043
Cameras directed at storage areas for high-cost noncontrolled medications	18/56 (32)	30/76 (39)	>0.05
Purchases periodically reconciled against dispensings for high-cost noncontrolled medications	14/58 (24)	32/76 (42)	0.043
Personal belongings banned from drug storage areas	14/59 (24)	28/76 (37)	>0.05
Packaging of high-cost noncontrolled medications defaced to inhibit diversion and resale	1/59 (2)	5/76 (7)	…^c
Operating Rooms
Controlled substances dispensed for an OR case always reconciled by pharmacy against products documented as administered or returned to the pharmacy for wasting	26/59 (44)	48/76 (63)	0.036
Controlled substances not used in an OR case returned to the pharmacy for wasting	12/59 (20)	43/76 (57)	0.001
Nursing Units
Decentralized ADMs used for controlled-substance distribution	55/59 (93)	76/76 (100)	…^c
ADM discrepancy resolution explanations "always" or "sometimes" investigated for validity	54/55 (98)	70/76 (92)	…^c
Use of system capable of electronically identifying discrepancies between central pharmacy vault withdrawals and nursing unit-based ADM receipts	51/55 (93)	74/76 (97)	…^c
Use of "blind" count (ADM user forced to enter inventory count when accessing a pocket)	51/56 (91)	66/75 (88)	>0.05
ADM discrepancies analyzed to identify individuals most frequently involved in discrepancies	38/57 (67)	55/76 (72)	>0.05
ADM stock outages investigated for potential diversion	34/56 (61)	43/75 (57)	>0.05
Biometric fingerprint scan used for ADM access	34/59 (58)	50/76 (66)	>0.05
Locking cases used to secure non-PCA controlled-substance infusion containers while being administered	20/58 (34)	27/74 (36)	>0.05
If diversion detection software used, flagged individuals are "always" or "sometimes" investigated for potential diversion	45/51 (88)	71/72 (99)	…^c
Diversion detection software flags users for controlled-substance ADM transaction counts significantly above peer group mean	40/58 (69)	66/76 (87)	0.018
Alert (e-mail, voice mail, pager) sent to pharmacy leaders when a specified ADM per-transaction threshold exceeded	14/53 (26)	25/71 (35)	>0.05

^aFor fractional data, numerator denotes number reporting use; denominator denotes number answering survey item. DEA = Drug Enforcement Administration, CSOS = controlled-substances ordering system, OR = operating room, ADM = automated dispensing machine, PCA = patient-controlled analgesia. ^bNot applicable to 29 institutions that use electronic systems other than CSOS. ^cData limitations precluded statistical analysis.

Table 3. Diversion Detection Software
Software Source	No. (%) Respondents
Software Source	Hospitals With 1–399 Beds (n = 41)	Hospitals With ≥400 Beds (n = 65)
Vendor of automated distribution software	25 (61)	31 (48)
Pandora Data Systems (Scotts Valley, CA)	8 (20)	15 (23)
Rx Auditor (Medacist Solutions Group, Cheshire, CT)	4 (10)	12 (19)
System developed in institution	2 (5)	3 (5)
Other	2 (5)	4 (6)

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